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Ackermann J, Baumann J, Pape J, Pahls J, Ruchay Z, Spüntrup C, Holthaus B, Noé G, Anapolski M, Meinhold-Heerlein I, Peters G, Willer D, Westermann A, Brügge S, Günther V, Maass N, Mettler L, Alkatout I. Factors influencing surgical performance and learning progress in minimally invasive surgery - results of an interdisciplinary multicenter study. Int J Surg 2023; 109:2975-2986. [PMID: 37462985 PMCID: PMC10583955 DOI: 10.1097/js9.0000000000000590] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/26/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Advancing surgical techniques require a high level of adaptation and learning skills on the part of surgeons. The authors need selection procedures and decision support systems for the recruitment of medical students and young surgeons. The authors aimed to investigate factors influencing the surgical performance and learning abilities of surgeons and medical students. MATERIALS AND METHODS The training scores of persons attending 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, individual characteristics, and the results of psychomotor tests of three-dimensional imagination and hand-eye coordination were correlated. Similar analyses were performed for medical students in their final clinical year from 2019 to 2020. The training concept was evaluated in a prospective, multicenter, interdisciplinary, multinational setting. RESULTS In all, 180 of 206 physicians (response rate 87.4%) and 261 medical students (response rate 100%) completed the multistage training concept successfully. Of personal characteristics, the strongest correlation was noted for good surgical performance and learning success, and the absolute number of performed laparoscopic surgeries ( r =0.28-0.45, P <0.001/ r =0.1-0.28, P <0.05). A high score on the spatial visualization ability test was also correlated with good surgical performance ( r =0.18-0.27, P <0.01). Among medical students with no surgical experience, however, age was negatively correlated with surgical performance, that is the higher the age, the lower the surgical performance ( r =0.13/ r =0.22, P <0.05/ P <0.001). CONCLUSION Individual factors (e.g. surgical experience, self-assessment, spatial visualization ability, eye-hand coordination, age) influence surgical performance and learning. Further research will be needed to create better decision support systems and selection procedures for prospective physicians. The possibilities of surgical training should be improved, promoted, and made accessible to a maximum number of surgical trainees because individual learning curves can be overcome even by less talented surgeons. Training options should be institutionalized for those attending medical school.
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Affiliation(s)
- Johannes Ackermann
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Jorun Baumann
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Julian Pape
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Julia Pahls
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Zino Ruchay
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | | | - Bernd Holthaus
- Clinic of Obstetrics and Gynecology, St. Elisabeth Hospital, Damme
| | - Günter Noé
- Department of Obstetrics and Gynecology, University Witten/Herdecke, Rheinland Klinikum Dormagen, Dormagen
| | - Michael Anapolski
- Department of Obstetrics and Gynecology, University Witten/Herdecke, Rheinland Klinikum Dormagen, Dormagen
| | - Ivo Meinhold-Heerlein
- Department of Gynecology and Obstetrics, University Hospital of Giessen, Giessen, Germany
| | - Göntje Peters
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Damaris Willer
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Anna Westermann
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Sandra Brügge
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Veronika Günther
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Nicolai Maass
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Liselotte Mettler
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
| | - Ibrahim Alkatout
- Kiel School of Gynaecological Endoscopy, Department of Gynaecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel
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Schützendübel M, Boosz A, Baev E, Häberle L, Müller A. Learning laparoscopic hysterectomy: analysis of different surgeons' individual learning curves. Arch Gynecol Obstet 2023; 307:1065-1072. [PMID: 36580116 DOI: 10.1007/s00404-022-06893-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/13/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The aim of this study was to examine the development of surgical skills among surgeons learning total laparoscopic hysterectomy (TLH), using differences in complication rates between surgeons with different levels of experience and analyzing the development of individual operating times. STUDY DESIGN This retrospective, single-center cohort study included 576 total laparoscopic hysterectomy procedures conducted between January 2015 and December 2019 at the municipal hospital in Karlsruhe, Germany. All TLHs were performed by eight surgeons, two of whom were experienced and six inexperienced. Complications were graded using the Clavien-Dindo classification. RESULTS No differences in complication rates were seen between experienced and inexperienced surgeons. With growing numbers of procedures, most surgeons quickly became faster, leading to reduced operating times. However, experienced surgeons who had performed more than 100 procedures also became faster, not reaching a time plateau after adjustment for weight of the uterus, presurgery score, and adnexal score. CONCLUSIONS Learning laparoscopic hysterectomy in routine practice is safe for patients, and surgeons rapidly become faster as growing numbers of procedures are performed. Operating times for experienced surgeons who have carried out more than 100 operations also improve, and a time plateau is not reached.
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Affiliation(s)
- Malte Schützendübel
- Department of Obstetrics and Gynecology, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany.
- Friedrich Alexander University of Erlangen-Nürnberg, Erlangen, Germany.
| | - Alexander Boosz
- Department of Obstetrics and Gynecology, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Evgeni Baev
- Department of Obstetrics and Gynecology, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Lothar Häberle
- Department of Obstetrics and Gynecology, Erlangen University Hospital, Erlangen, Germany
| | - Andreas Müller
- Department of Obstetrics and Gynecology, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany
- Friedrich Alexander University of Erlangen-Nürnberg, Erlangen, Germany
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Tummers FHMP, Hoebink J, Driessen SRC, Jansen FW, Twijnstra ARH. Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: An undesired side effect? Acta Obstet Gynecol Scand 2021; 100:2082-2090. [PMID: 34490608 DOI: 10.1111/aogs.14242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/13/2021] [Accepted: 08/08/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The implementation of advanced minimally invasive surgical (MIS) techniques has broadened. An extensive body of literature shows that high hospital and surgeon volumes lead to better patient outcomes. However, no information is available regarding volume trends in the post-implementation phase of MIS. This study investigated these trends and poses suggestions to adjust these developments. This knowledge can provide guidance to optimize patient safe performance of new surgical techniques. MATERIAL AND METHODS A national retrospective cohort study in the Netherlands. The number of advanced laparoscopic (level 3 and 4) and robotic procedures and the number of gynecologists performing them were collected through a web-based questionnaire to determine hospital and gynecological surgeon volume. These volumes were compared with our previously collected data from 2012. RESULTS The response rate was 85%. Hospitals produced larger volumes for advanced laparoscopic and robotic procedures. However, still 63% of the hospitals perform low-volume level 4 laparoscopic procedures. Additionally, gynecological surgeon volumes appeared to decrease for level 3 procedures, as the group of gynecologists performing fewer than 20 procedures expanded (64% vs. 44% in 2012), with 15% of the gynecologists performing fewer than ten procedures. Despite an increase in surgeon volumes for level 4 laparoscopy and robotic surgery, volumes continued to be low, as still 49% of gynecologists performed fewer than 10 level 4 procedures per year and 41% performed fewer than 20 robotic procedures per year. CONCLUSIONS The broad implementation of advanced MIS procedures resulted in an increasing number of these procedures with increasing hospital volumes. However, as a side-effect, a disproportionate rise in number of gynecologists performing these procedures was observed. Therefore, surgeon volumes remain low and even decreased for some procedures. Centralization of complex procedures and training of specialized MIS gynecologists could improve surgeon volumes and therefore consequently enhance patient safety.
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Affiliation(s)
| | - Jasmin Hoebink
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sara R C Driessen
- Department of Gynecology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Bio Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
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Pepin K, Cook F, Maghsoudlou P, Cohen SL. Risk-prediction Model for Patients Undergoing Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2021; 28:1751-1758.e1. [PMID: 33713836 DOI: 10.1016/j.jmig.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Develop a model for predicting adverse outcomes at the time of laparoscopic hysterectomy (LH) for benign indications. DESIGN Retrospective cohort study. SETTING Large academic center. PATIENTS All patients undergoing LH for benign indications at our institution between 2009 and 2017. INTERVENTIONS LH (including robot-assisted and laparoscopically assisted vaginal hysterectomy) was performed per standard technique. Data about the patient, surgeon, perioperative adverse outcomes (intraoperative complications, readmission, reoperation, operative time >4 hours, and postoperative medical complications or length of stay >2 days), and uterine weight were collected retrospectively. Pathologic uterine weight was used as a surrogate for predicted preoperative uterine weight. The sample was randomly split, using a random sequence generator, into 2 cohorts, one for deriving the model and the other to validate the model. MEASUREMENTS AND MAIN RESULTS A total of 3441 patients were included. The rate of composite adverse outcomes was 14.1%. The final logistic regression risk-prediction model identified 6 variables predictive of an adverse outcome at the time of LH: race, history of laparotomy, history of laparoscopy, predicted preoperative uterine weight, body mass index, and surgeon annual case volume. Specifically included were race (97% increased odds of an adverse outcome for black women [95% confidence interval (CI), 34%-110%] and 34% increased odds of an adverse outcome for women of other races [95% CI, -11% to 104%] when compared with white women), history of laparotomy (69% increased odds of an adverse outcome [95% CI, 26%-128%]), history of laparoscopy (65% increased odds of an adverse outcome [95% CI, 21%-124%]), and predicted preoperative uterine weight (2.9% increased odds of an adverse outcome for each 100-g increase in predicted weight [95% CI, 2%-4%]). Body mass index and surgeon annual case volume also had a statistically significant nonlinear relationship with the risk of an adverse outcome. The c-statistic values for the derivation and validation cohorts were 0.74 and 0.72, respectively. The model is best calibrated for patients at lower risk (<20%). CONCLUSION The LH risk-prediction model is a potentially powerful tool for predicting adverse outcomes in patients planning hysterectomy.
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Affiliation(s)
- Kristen Pepin
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou); Department of Minimally Invasive Gynecologic Surgery, Weill Cornell Medicine, New York, New York (Dr. Pepin).
| | - Francis Cook
- Department of Epidemiology, Harvard School of Public Health (Dr. Cook), Boston, Massachusetts
| | - Parmida Maghsoudlou
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou)
| | - Sarah L Cohen
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou); Department of Minimally Invasive Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota (Dr. Cohen)
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A Strategy for Risk-adjusted Ranking of Surgeons and Practices Based on Patient-reported Outcomes After Elective Lumbar Surgery. Spine (Phila Pa 1976) 2019; 44:670-677. [PMID: 30312268 DOI: 10.1097/brs.0000000000002894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study retrospectively analyzes prospectively collected data. OBJECTIVE The primary aim of this study is to present a scheme for patient-reported outcome (PRO)-based, risk-adjusted rankings of spine surgeons and sites that perform elective lumbar surgery, using the Quality and Outcomes Database (QOD). SUMMARY OF BACKGROUND DATA There is currently no means of determining which spine surgeons or centers are positive or negative outliers with respect to PROs for elective lumbar surgery. This is a critical gap as we move toward a value-based model of health care in which providers assume more accountability for the effectiveness of their treatments. METHODS Random effects regression models were fit for the following outcomes, with QOD site as a fixed effect but surgeon ID as a random effect: Oswestry Disability Index, EQ-5D, back pain and leg pain, and satisfaction. Hierarchical Bayesian models were also fit for each outcome, with QOD site as a random effect and surgeon as a nested random effect. RESULTS Our study cohort consists of 8834 patients who underwent surgery by 124 QOD surgeons, for the degenerative lumbar diseases. Nonoverlapping Bayesian credible intervals demonstrate that the variance attributed to QOD site was greater than the nested variance attributed to surgeon ID for the included PROs. CONCLUSION This study presents a novel strategy for the risk-adjusted, PRO-based ranking of spine surgeons and practices. This can help identify positive and negative outliers, thereby forming the basis for large-scale quality improvement. Assuming adequate coverage of baseline risk adjustment, the choice of surgeon matters when considering PROs after lumbar surgery; however, the choice of site appears to matter more. LEVEL OF EVIDENCE 3.
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Impact of Surgeon Self-evaluation and Positive Deviance on Postoperative Adverse Events After Non-cardiac Thoracic Surgery. J Healthc Qual 2018; 40:e62-e70. [DOI: 10.1097/jhq.0000000000000130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naveiro-Fuentes M, Rodríguez-Oliver A, Fernández-Parra J, González-Paredes A, Aguilar-Romero T, Mozas-Moreno J. Effect of surgeon's experience on complications from laparoscopic hysterectomy. J Gynecol Obstet Hum Reprod 2017; 47:63-67. [PMID: 29154851 DOI: 10.1016/j.jogoh.2017.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/31/2017] [Accepted: 11/08/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the effect of learning in two surgeons on complications and conversion to laparotomy during total and subtotal laparoscopic hysterectomy. MATERIAL AND METHODS We analyzed retrospectively 236 total and subtotal laparoscopic hysterectomies done by two surgeons from the time they first performed the procedure. The interventions were classified in three groups based on the surgeon's experience: the first 75 hysterectomies ("novice period"), the subsequent 75 hysterectomies ("intermediate"), and the subsequent 86 hysterectomies ("routine period"). RESULTS Patient's characteristics changed as surgeons gained experience, with more complex operations (greater obesity, previous surgery and malignant disease) becoming more frequent. During the second group of operations when surgeons had an intermediate level of experience, the risk of major complications decreased (adjusted odds ratio: 0.28, 95% confidence interval: 0.10-0.85), as did the risk of type III complications of Clavien-Dindo classification (adjusted odds ratio 0.15, 95% confidence interval: 0.03-0.93). However, the percent rate of conversion to laparotomy remained stable in the second (intermediate experience) group. In the third group, after the surgeons had performed 150 procedures and when the risk of any type of complication was lowest, the risk of conversion to laparotomy decreased compared to the routine group. CONCLUSIONS The surgeon's experience in performing laparoscopic hysterectomy plays an essential role in the decrease in the risk of complications, and this finding supports the importance of providing appropriate training for residents and gynecologists to enable them to perform this procedure with an optimal degree of competence and safety.
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Affiliation(s)
- M Naveiro-Fuentes
- Department of obstetrics and gynecology, hospital Materno-Infantil, Avda. Fuerzas Armadas sn, 18014 Granada, Spain.
| | - A Rodríguez-Oliver
- Department of obstetrics and gynecology, hospital Materno-Infantil, Avda. Fuerzas Armadas sn, 18014 Granada, Spain
| | - J Fernández-Parra
- Department of obstetrics and gynecology, hospital Materno-Infantil, Avda. Fuerzas Armadas sn, 18014 Granada, Spain
| | - A González-Paredes
- Department of obstetrics and gynecology, hospital Materno-Infantil, Avda. Fuerzas Armadas sn, 18014 Granada, Spain
| | - T Aguilar-Romero
- Department of obstetrics and gynecology, hospital Materno-Infantil, Avda. Fuerzas Armadas sn, 18014 Granada, Spain
| | - J Mozas-Moreno
- Department of obstetrics and gynecology, hospital Materno-Infantil, Avda. Fuerzas Armadas sn, 18014 Granada, Spain
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